Acne vulgaris is the most common condition treated by physicians worldwide. Though most acne patients remit spontaneously, for the ones that do not or are unresponsive to conventional therapy or have obvious cutaneous signs of hyperandrogenism, hormonal therapy is the next option in the therapeutic ladder. It is not strictly indicated for only those patients who have cutaneous or biochemical evidence of hyperandrogenism, but can be used even without any evidence of hyperandrogenism, for therapy-resistant acne. It can be prescribed as monotherapy, but when used in combination with other conventional therapies, it may prove to be more beneficial. Hormonal evaluation is a prerequisite for hormonal therapy, to identify the cause behind hyperandrogenism, which may be ovarian or adrenal. This article reviews guidelines for patient selection and the various available hormonal therapeutic options, their side-effect profile, indications and contraindications, and various other practical aspects, to encourage dermatologists to become comfortable prescribing them.

Background: Calcitriol is well known for its therapeutic efficacy in psoriasis, but its mechanism of action is still unclear. In this study, we tried to elucidate the precise mechanism of calcitriol for its therapeutic efficacy in psoriasis. Materials and Methods: Proliferation and apoptosis studies were done to determine the effect of calcitriol on normal human epidermal keratinocytes (NHEKs) and T lymphocytes. To elucidate the effect of Calcitriol on relevant chemokines and epidermal proteins of psoriasis, real-time polymerase chain reaction were done on the modified reconstructed human epidermis (RHE) an in vitro model of psoriasis. All experiments were done in triplicate. Results were expressed as mean ± standard error of mean. Results and Conclusions:In vitro, Calcitriol showed significant inhibition of NHEKs and T lymphocyte proliferation by inducing apoptosis of these cells. Moreover, in an in vitro model of psoriasis (RHE), Calcitriol significantly inhibited relevant gene expression of chemokines (Interleukin-8, Regulated upon Activation Normal T-cell Expressed and Secreted [RANTES]) and psoriasin (S100A7). Here, we observed that Calcitriol inhibits critical pathological events associated with the inflammatory-proliferative cascades of psoriasis. Calcitriol induced apoptosis of NHEKs and T lymphocytes as well as inhibited gene expression of relevant chemokines and epidermal proteins in the in vitro model of psoriasis.

The need for understanding and reflecting on evidence-based dermatology (EBD) has never been greater given the exponential growth of new external evidence to inform clinical practice. Like any other branch of medicine, dermatologists need to acquire new skills in constructing answerable questions, efficiently searching electronic bibliographic databases, and critically appraising different types of studies. Secondary summaries of evidence in the form of systematic reviews (SR), that is, reviews that are conducted in a systematic, unbiased and explicit manner, reside at the top of the evidence hierarchy, because they are less prone to bias than traditional expert reviews. In addition to providing summaries of the best external evidence, systematic reviews and randomized controlled trials (RCTs) are also powerful ways of identifying research gaps and ultimately setting the agenda of future clinical research in dermatology. But like any paradigm, EBD can have its limitations. Wrong application, misuse and overuse of EBD can have serious consequences. For example, mindless pooling together of data from dissimilar studies in a meta-analysis may render it a form of reductionism that does not make any sense. Similarly, even highly protocolised study designs such as SRs and RCTs are still susceptible to some degree of dishonesty and bias. Over-reliance on randomized controlled trials (RCT) may be inappropriate, as RCTs are not a good source for picking up rare but important adverse effects such as lupus syndrome with minocycline. A common criticism leveled against SRs is that these frequently conclude that there is lack of sufficient evidence to inform current clinical practice, but arguably, such a perception is grounded more on the interpretation of the SRs than anything else. The apparent absence of evidence should not paralyze the dermatologist to adopt a state of therapeutic nihilism. Poor primary data and an SR based on evidence that is not up-to-date are also limitations that can only improve with better primary studies and updated reviews such as those done by the Cochrane Collaboration. Most dermatologists are interested in integrating the best external evidence with the care of individual patients and have been practicing good EBD without realizing it.

A systematic review is a summary of existing evidence that answers a specific clinical question, contains a thorough, unbiased search of the relevant literature, explicit criteria for assessing studies and structured presentation of the results. A systematic review that incorporates quantitative pooling of similar studies to produce an overall summary of treatment effects is a meta-analysis. A systematic review should have clear, focused clinical objectives containing four elements expressed through the acronym PICO ( Patient, group of patients, or problem, an Intervention, a Comparison intervention and specific O utcomes). Explicit and thorough search of the literature is a pre-requisite of any good systematic review. Reviews should have pre-defined explicit criteria for what studies would be included and the analysis should include only those studies that fit the inclusion criteria. The quality (risk of bias) of the primary studies should be critically appraised. Particularly the role of publication and language bias should be acknowledged and addressed by the review, whenever possible. Structured reporting of the results with quantitative pooling of the data must be attempted, whenever appropriate. The review should include interpretation of the data, including implications for clinical practice and further research. Overall, the current quality of reporting of systematic reviews remains highly variable.

Evidence - based pharmacological treatment of atopic dermatitis: An expert opinion and new expectations

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Arnold P OranjeDOI:10.4103/0019-5154.127673 PMID:24700931

Atopic dermatitis (AD) is one of the most common skin diseases with a complex multifactorial background. The clinical presentation, the aggravating factors and the complications vary according to the age of the patients. Most cases, approximately 60-80%, present for the 1 st time before the age of 12 months. Adult-onset AD has been observed as a special variant. Pruritus is the worst sign of AD, which also often indicates an exacerbation and is considered to be the most annoying symptom of AD. Treatment is preferably started based on the severity of AD. In only 10% of the cases, AD is so severe that systemic treatment is necessary. Systemic treatment including topical wet-wrap treatment is indicated in the worst and recalcitrant cases of AD. Systemic treatment of AD is discussed with regards to the evidence-based efficacy and safety aspects. I prefer wet-wraps as a crisis intervention in severe childhood cases, whereas UV and systemic treatments are the choices in patients older than 10 years. Probiotics are not useful in the treatment. If they have any effect at all it may only be in food-allergic children with AD. Finally, anti-histamines are not effective against pruritus in AD. They are only effective against urticarial flares and in cases with food-allergy. This article consists of an expert opinion on evidence-based pharmacological treatment of AD, but it is not a systemic review.

Context: The uncontrolled use of antibiotics has resulted in a relentless spread of multiresistant strains of Staphylococcus aureus. There are studies conducted in medical colleges in Chandigarh, Chennai, Mumbai and Vellore comparing pyodermas in the community and hospital setting based on clinical and bacteriological parameters. Aims: This study, conducted over 1½ years from March 2009 to August 2010, aimed at analyzing the clinical spectrum and antibiotic sensitivity pattern of community and hospital-associated (HA) staphylococcal pyoderma. It also assessed the prevalence of methicillin-resistant S. aureus (MRSA) in the community and hospital cohort settings. Subjects and Methods: The study comprised of 200 cases of staphylococcal pyodermas, derived from the community (150 cases) and hospital (50 cases). Patients were evaluated based on their clinical presentation; antibiotic susceptibility was tested using the Kirby-Bauer disk diffusion method. Statistical Analysis Used: Statistical significance between individual attributes between the community and HA staphylococcal pyoderma groups was analyzed using Chi-square test and mean differences using student's t-test. Results: Factors associated with community-associated (CA) pyodermas were young age (P = 0.0021), primary pyodermas, and involvement of extremities, while those with HA pyodermas were middle age, secondary pyodermas, and significantly increased body surface involvement (P = 0.041). Incidence of CA-MRSA was 11.3%, while that of HA-MRSA was 18%. Conclusions: A high level of resistance to first-line drugs such as penicillin, ciprofloxacin and cotrimoxazole was observed, more so in the hospital strain than in the community strain. S. aureus demonstrated good susceptibility to cephalosporins. Though the two strains of MRSA differed clinically, they showed 100% sensitivity to vancomycin and linezolid.

Background: Periorbital hyperpigmentation (POH) is one of the most commonly encountered conditions in routine dermatology practice. There are only few published studies about its prevalence, classification, and pathogenesis but none showing its association with habits, and other medical conditions in Indian patients. Aims: To determine prevalence and type of POH, common causative factors, and its association with personal habits and other disorders within various age and sex groups. Materials and Methods: Two hundred patients attending the dermatology OPD were included in study and were subjected to detailed history, careful clinical and Wood's lamp examination, eyelid stretch test and laboratory investigations. Clinical photographs of all patients were taken. Results: POH was most prevalent in 16-25 years age group (47.50%) and in females (81%) of which majority were housewives (45.50%). Commonest form of POH was constitutional (51.50%) followed by post inflammatory (22.50%). Lower eyelids were involved in 72.50%. Grade 2 POH was seen in 58%. Wood's lamp examination showed POH to be dermal in 60.50%. Faulty habits were observed viz. lack of adequate sleep (40%), frequent cosmetic use (36.50%), frequent eye rubbing (32.50%), and lack of correction for errors of refraction like myopia in 12% patients. Strong association of POH with stress (71%), atopy (33%) and family history (63%) was noted. Conclusions: Periorbital hyperpigmentation is a multi-factorial entity. It is absolutely essential to classify the type of POH and determine underlying causative factors in order to direct appropriate measures for better and successful outcome in future.

Introduction: Early diagnosis and early adequate drug treatment is very important aspect to reduce the load in cases of leprosy. So, correct labeling of paucibacillary and multibacillary cases is a prerequisite for the adequate treatment. Confirmation of diagnosis is an important indication for histopathological examination in doubtful cases. Objectives: The present study was carried out to know the clinical profile of leprosy patients, concordance between clinical and histopathological diagnosis in cases of leprosy, and to assess the therapeutic efficacy of antileprosy therapy. Study Design: Two hundred and fifty clinically diagnosed leprosy patients attending skin outdoor patient department (OPD) were included in the study. Slit skin smear was performed in all the cases. In that case concordance between clinical and histology can be determined only in 30 cases. All the patients were treated with MDT (multidrug therapy) as per WHO guideline. Results: A total of 250 patients attended the clinic with male to female ratio of 1.7:1. The highest incidence was noted in 17-40 years of age group. In the clinical disease spectrum, 40% patients were in the borderline spectrum followed by tuberculoid leprosy (TT) (29.2%), lepromatous leprosy (LL) (26.8%), and 3.9% of indeterminate leprosy (IL). A total of 18% of patients were of primary neuritic leprosy. A total of 8.3% patients had definite history of contact in the family or neighborhood. Clinicopathological correlation was noted in 60% of patients with maximum disparity (52.9%) in the borderline group of patients. A total of 52.8% were MB (Multibacillary) and 47.2% were PB (Paucibacillary) cases. Morphological index became negative after 6 months in all patients. Mean fall of bacteriological index after 6 months was 0.19, while after 1 year, it was 1.05. Conclusion: Timely diagnosis and adequate treatment of cases with MDT is most effective. Histopathological examination is must in doubtful cases of leprosy.

Efficacy of finasteride for treating patients with androgenetic alopecia who are pileous in other areas: A pilot study in Japan

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Toru InadomiDOI:10.4103/0019-5154.127677 PMID:24700935

Background: Androgenetic alopecia (AGA) involves androgen-dependent hair loss and finasteride is an established treatment for the disease. However, reports of the influence of finasteride on hair growth in other areas of the body are lacking. Aims: To investigate the effects of finasteride on hair, including the head and other areas of the body. Materials and Methods: Based on whether AGA patients felt they were pileous in areas other than the head, they were divided into Group A (pileous) or Group B (not pileous). Finasteride (1 mg/day) was prescribed for both groups for at least 6 months, after which patients were asked to estimate the medicine's effects and any changes of their hair growth. Results and Conclusions: A total of 18 out of 37 patients were placed in Group A and 19 of them were in Group B, suggesting that about half of AGA patients in Japan are pileous in other parts of the body. Oral finasteride was effective (excellent or good) in 22 out of 37 (59.5%) patients overall, in 16 out of 18 (88.9%) patients in Group A, and in 6 out of 19 (31.6%) patients in Group B. None of the patients reported that oral finasteride had any effect on their hair growth other than on their head. Finasteride is more effective for treating AGA patients who are pileous in other areas of the body.

Hypnotherapy is a useful adjunctive psychotherapeutic procedure used in various conditions such as pain disorders, atopic dermatitis, and alopecia areata. However, it is less utilized in the field of dermatology. Only limited data exist on its role in the management of various skin diseases. There is dearth of literature on the role of hypnotherapy in Hansen's disease (HD). We report two cases of HD, one with very resistant neuralgia and the other with recurrent erythema nodosum leprosum (ENL). Both the patients were assessed using hospital anxiety and depression scale, dermatology life quality index and the neuralgia was assessed using the visual analog scale. Three sessions of hypnotherapy were given to both the patients. There was dramatic improvement in the incidence of ENL and neuralgia and we could rapidly reduce the dose of drugs used for both conditions.

Background: The search for alternative and effective forms of training simulation is needed due to ethical and medico-legal aspects involved in training surgical skills on living patients, human cadavers and living animals. Aims : To evaluate if the bench model fidelity interferes in the acquisition of elliptical excision skills by novice medical students. Materials andMethods: Forty novice medical students were randomly assigned to 5 practice conditions with instructor-directed elliptical excision skills' training (n = 8): didactic materials (control); organic bench model (low-fidelity); ethylene-vinyl acetate bench model (low-fidelity); chicken legs' skin bench model (high-fidelity); or pig foot skin bench model (high-fidelity). Pre- and post-tests were applied. Global rating scale, effect size, and self-perceived confidence based on Likert scale were used to evaluate all elliptical excision performances. Results : The analysis showed that after training, the students practicing on bench models had better performance based on Global rating scale (all P < 0.0000) and felt more confident to perform elliptical excision skills (all P < 0.0000) when compared to the control. There was no significant difference (all P > 0.05) between the groups that trained on bench models. The magnitude of the effect (basic cutaneous surgery skills' training) was considered large (>0.80) in all measurements. Conclusion : The acquisition of elliptical excision skills after instructor-directed training on low-fidelity bench models was similar to the training on high-fidelity bench models; and there was a more substantial increase in elliptical excision performances of students that trained on all simulators compared to the learning on didactic materials.

Radiation therapy is associated with a variety of complications, including the development of primary skin cancers in the radiated region. However, it is rare for patients with visceral cancers who are treated with radiation therapy to subsequently develop cutaneous metastasis within the radiation port. We describe two patients with internal malignancies who developed cutaneous metastases within their radiation ports following radiotherapy. In addition, we used PubMed to perform an extensive literature review and identify additional reports of cutaneous metastasis within a radiation port. We excluded patients who developed melanoma or primary skin cancers in the radiation port. We also excluded patients with non-solid organ malignancies. Herein, we summarize the characteristics of 23 additional patients who experienced radiation port cutaneous metastases and explore possible mechanisms for the occurrence of radiation port cutaneous metastases.

Acute progressive disseminated histoplasmosis (PDH) may be the initial manifestation of human immunodeficiency virus (HIV). However, cutaneous involvement is very rare. We present an unusual case of acute PDH with multiple diffuse cutaneous papulonodular lesions predominantly on the face, trunk, and upper extremities, diagnosed initially with fine needle aspiration cytology (FNAC). Subsequent serological tests revealed positivity for antibodies for HIV 1 and 2. The cytomorphological features were further confirmed by biopsy and histochemical stains. FNAC is a rapid, cost-effective tool that may be utilized in the diagnosis of papulonodular forms of PDH and for initiating prompt therapy. We discuss the clinical features, clinical differentials, and treatment of the condition.

A 40-year-old lady presented with history of multiple red raised painful lesions over her body of 10 days duration. Lesions spread from forearms to arms and back of trunk during the progress of the disease. Associated pain and burning sensation in the lesions was present while working in the sun. Mild to moderate grade fever, malaise, pain over large joints, decreased appetite, and redness of eyes was also present. There was no history of drug intake or other risk-factors. Dermatological examination revealed erythematous papules coalescing to form plaques with a pseudovesicular appearance over the extensor aspect of forearms and photo-exposed areas on the back of trunk. There was a sharp cut-off between the lesions and the photo-protected areas. Investigations revealed anemia, neutrophilic leukocytosis, raised erythrocyte sedimentation rate and positive C reactive protein. Skin biopsy showed characteristic features of Sweet's syndrome. No evidence for any secondary etiology was found. She responded to a tapering course of oral steroids and topical broad spectrum photo-protection. This case is a very rare instance of idiopathic Sweets syndrome occurring in a photo-distributed pattern.

Familial benign chronic pemphigus or Hailey-Hailey disease (HHD) is a rare autosomal dominant disorder characterized by the development of recurrent blisters and erosions in the intertriginous areas. Various topical and systemic treatment options include corticosteroids, topical 5-fluorouracil, topical vitamin D analogs, topical zinc oxide, dapsone, psoralen plus ultraviolet A, systemic retinoids, cyclosporine, methotrexate, and photodynamic therapy. In recalcitrant cases, further options including, invasive methods such as grenz ray therapy, carbon dioxide laser abrasion, and erbium: YAG laser ablation, dermabrasion, electron beam therapy, botulinum toxin, and full-thickness excision of affected skin with repair by split-thickness grafting have been reported as useful in treatment of HHD. We describe a case of HHD who was treated with several treatment modalities including antibiotics, corticosteroids, and dapsone earlier and when presented to us had a severe recalcitrant disease. Thalidomide, as a modality of treatment has been successfully used in few cases earlier. Our patient responded well to thalidomide.

Ultraviolet radiation is an important risk factor for the development of skin cancers. Melanin is known to protect the skin against harmful effects of ultraviolet radiation. Hence, vitiligo patients are at higher risk of developing such malignancies. But few reports of occurrence of skin cancers in vitiligo lesions suggest that their occurrence in vitiligo is rare. There are reports of development of Squamous cell carcinoma (SCC) in vitiligo lesions, following long-term Psoralen and Ultraviolet-A (PUVA) therapy. But there are no reports of occurrence of SCC in a vitiligo patch located in photo-covered area. We describe a patient with SCC in a vitiligo patch present in photo-covered skin.

Anticentromere antibodies have been associated with peripheral vascular occlusive disease, but then it is mostly accompanied by sclerodactyly in the context of a connective tissue disorder. We report a case of digital gangrene in a 75 year old lady with no other associations except positive anticentromere antibodies.

Background: Vitiligo is a common, acquired, pigmentary disorder characterized by loss of melanocytes resulting in white spots. This disease carries a lot of social stigma in India. Objective: To study the clinico-epidemiological profile of vitiligo patients in Kumaun region of Uttarakhand state in India. Materials and Methods: The clinical presentation of vitiligo was examined and analyzed in 762 vitiligo patients attending the Dermatology outdoor of Government Medical College, Haldwani, which is a referral centre for Kumaun region of Uttarakhand state in India. Results: Male and female patients were found to be affected almost equally. It was observed that onset of vitiligo was most common in 0-10 years age group, as evidenced by 336 cases out of 762 cases. Acrofacial type of vitiligo (339 cases out of 762) was most commonly observed, followed by vitiligo vulgaris, focal, segmental, mucosal, mixed, and universal vitiligo. The most common site of onset was the lower limbs followed by head and neck, upper limbs, trunk, genitalia, and mucasae. Leucotrichia was observed in 33.5%, Koebner's phenomenon in 26.3%, and a positive family history in 19% of the vitiligo patients. The other common conditions associated were thyroid disorders (8.9%), diabetes (5.3%), and atopic dermatitis (4.9%). Conclusion: The study indicates that acrofacial vitiligo is the most common clinical type observed in Kumaun region of Uttarakhand in India. Onset of vitiligo is most common in first decade of life.

Background: There are very little elaborative studies in India about various patterns of skin diseases and various factors those influence the diseases in a tertiary institution. Aims: To find out the various patterns of skin diseases in relation to age, sex, occupation, and socio-economic status. To find out the magnitude of skin diseases and compare with other similar studies . Materials and Methods: Collection of data of all new skin cases in a specified period of one year and put on proforma for diagnosis. Few investigations were done for correct diagnosis. Results: It was found that skin OPD patients (new) were 4.16% of total new OPD patients, and male female ratio was 1.1:1. Among all patients (12910), infection was commonest (39.54%), followed by allergic skin disorder (29.20%). 25.05% patients were housewives, followed by students (23.21%). Study showed that 33.28% patients had per capita income of ` 361-720/month, and 22.35% patients were educated and/or studied up to class V. Conclusion: Pattern of skin diseases are mostly depend not only on environmental factors but also on occupation, socio-economic status, literacy, and age of the patients.

Background: Systemic oral psoralens plus UVA therapy (PUVA) is a therapeutic method used with considerable success in many different skin disorders. PUVA therapy causes some cutaneous and noncutaneous side effects and in the present research we deal with cutaneous side effects. Aims: Evaluation of patients to know the different skin side effects of PUVA and their importance. Materials and Methods: All patients referred to the phototherapy unit of Imam Reza Hospital of Mashhad entered the research and skin examination was taken place initially and every 3 months thereafter. Whenever any side effect appeared, it was recorded in the information sheet. Results: One hundred and twenty-eight patients were included in the research, 61 were male between 15 and 75 years and 67 were female between 10 and 61 years of age. Age of female patients at the time of cutaneous side effect appearance was less than male patients. The most common early side effect was pruritus (34.3%) and the rarest was telangiectasia (0.7%). One case of late side effect in the form of squamous cell carcinoma was observed in a patient who had received other carcinogenic drugs as well. Complications such as skin dryness, pruritus, erythema and burning sensation occurred at low doses of UVA, while dermatitis, severe limb pain and acne at moderate doses and PUVA lentigines, hypertrichosis and lichenoid lesions appeared at high doses of UVA. Conclusion: Considering the significant therapeutic effects and few serious side effects, PUVA therapy is a suitable and safe method for treatment of certain skin diseases.

A 26-year-old Chinese male consulted with the team regarding his alopecia areata and vitiligo for which previous treatment was ineffective. The patient, a homosexual man, denied having a history of drug abuse and of blood transfusion. No member of his family had vitiligo or alopecia. Laboratory studies revealed that the serum for anti-human immunodeficiency virus (HIV) antibody was positive. The patient's CD4 lymphocyte count and CD4/CD8 ratio were both strikingly low (20 cells/mL and 0.04), but no other complaints or opportunistic infections were reported. One month after antiretroviral therapy, the patient's alopecia areata dramatically improved, but no evident improvement in his vitiligo was found. This case is a very rare case of alopecia areata and vitiligo associated with HIV infection that might be attributed to the generation and maintenance of self-reactive CD8+ T-cells due to chronic immune activation with progressive immune exhaustion in HIV infection.

Hepatitis being first manifestation of secondary syphilis is rare. Here in we report a case of 39 years old male who was being treated for hepatitis and presented to us subsequently with itchy maculopapular rash. Venereal disease research laboratory (VDRL) titre was 1:16. Treponema pallidum hemagglutination assay (TPHA) was positive. He was treated with intramuscular Benzathine Penicillin. His hepatitis improved rapidly.

Pemphigus vegetans is a rare variant of pemphigus vulgaris. A 62-year-old woman presented with erythematous moist vegetative plaque on the left breast and left groin. There was no mucosal involvement. Histopathological and direct immunofluorescence findings were suggestive of pemphigus vegetans. She showed excellent response to oral steroids. Literature is scarcely available on the limited involvement with pemphigus vegetans without mucosal involvement.

Epidermal nevus syndromes are rare conditions, characterized by different types of keratinocytic or organoid epidermal nevi in association with ocular, neurological, and skeletal manifestations. We present a case of late onset epidermal nevus with hypertrichosis and hemihypertrophy of face. Genetic analysis did not reveal presence of FGFR3 or PIK3CA mutations. The patient has features that cannot be categorized into the present well-known syndromes.

Acute generalized exanthematous pustulosis (AGEP) is a rare drug induced cutaneous hypersensitivity reaction characterized by sudden onset of fever with sterile pustules overlying an erythematous skin occurring all over the body. The offending drugs are usually B-lactams and macrolides.Among anticonvulsants carbamazepine and Phenobarbital are commonly associated with AGEP. Only one case of phenytoin induced AGEP has been reported in literature. We present a rare case of AGEP with cerebellar syndrome occurring after receiving loading dose of phenytoin.

Tumid lupus erythematosus (LE) is a rare variant of lupus erythematosus, which often follows a favorable course. A case of a young woman is illustrated, who presented with an asymptomatic erythematous, solitary plaque over her face. Histopathological and direct immunofluorescence examination established a diagnosis of tumid lupus erythematosus. She responded slowly and near-completely to hydroxychloroquine sulfate; however, a flare up occurred a month later. Addition of topical tacrolimus 0.1% resulted in complete regression without leaving any residual changes. No recurrence was seen subsequently.